"Misuses of EBM"

In an excellent article(1) just published in JAMA on progress in evidence-based medicine, Montori and Guyatt devote a section to the misuses of EBM, worth quoting in its entirety herewith emphasis added.

An analogy can be made between EBM and nuclear fission: it can be very powerful when used appropriately and dangerous when used inappropriately. The term evidence-based precedes many recommendations, guidelines, and algorithms that are not transparently linked to the underlying evidence base and do not represent the results of a systematic and critical appraisal of that evidence. It sometimes appears as if using the term obviates the need to describe the quality of underlying evidence, the magnitude of effects, or the applicability of any of the results in the context, values, and preferences of the patients.

This is particularly problematic because the EBM era has coincided with a dramatic increase in the for-profit funding of research. Researchers funded by industry interpret their results differently and in favor of the industry product relative to not-for-profit funding. Problems associated with industry funding include use of inappropriate control interventions, surrogate outcomes, publication and reporting bias, and misleading descriptions and presentations of research findings—all forms of corrupting the evidence base. Unsophisticated users of the medical literature, assuming that medical editors, peer reviewers, and topic experts have now become familiar with the tenets of EBM, may trust these corrupted research reports and advocate for their application in practice.

Many medical schools and training programs, in a form of premature closure, are moving away from teaching the fundamentals of careful evidence appraisal to emphasize the implementation of evidence. The intent of this new focus is to produce high-quality, safe, and low-cost care (ie, Accreditation Council for Graduate Medical Education competencies of systems-based practice and improvement and practice-based learning14). However, abandoning appropriate skepticism regarding the effectiveness of these interventions may lead to large investments in quality-improvement, safety, and efficiency activities that fail to yield the expected benefits.

We are truly making progress when there is now such public recognition of threats to evidence-based medicine, and thus to the rational and compassionate practice of medicine based clinical knowledge, and on both critical review of the best available clinical evidence, and sensitivity to patients' values.

I should underline the points made in the last paragraph quoted. It is distressing that what little progress in making evidence-based medicine part of medical education we made in the 1980s and 1990s is being wiped out. But what should we expect of medical schools staffed by faculty and faculty leaders who mostly are paid by the companies that make the drugs and devices that are the subject of their teaching and research?(2-3) And what should we expect of medical schools that now depend on large infusions of money from these same companies? Truly rigorous EBM might actually show that some of these "innovative" drugs and devices are not quite as good as the marketing says. So teaching same may distress the faculty's employers and the university's benefactors.

If we expect the teaching of rational and compassionate medicine that puts the benefit of patients first, we need medical schools and medical faculty who are not paid by companies whose first priority is increasing profits by selling as many drug doses and devices they can.

References

1. Montori VM, Guyatt GH. Progress in evidence-based medicine. JAMA 2008; 300: 1814-1816. Link here.

2. Campbell EG, Gruen RL, Mountford J et al. A national survey of physician–industry relationships. N Engl J Med 2007; 356:1742-1750. Link here.

3. Campbell EG, Weissman JS, Ehringhaus S et al. Institutional academic-industry relationships. JAMA 2007; 298: 1779-1786. Link here.